Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery
Authors: Maura Marcucci, Thomas W. Painter, David Conen, Vladimir Lomivorotov, Daniel I. Sessler, Matthew T.V. Chan, Flavia K. Borges, Kate Leslie, Emmanuelle Duceppe, María José Martínez-Zapata, Chew Yin Wang, Denis Xavier, Sandra N. Ofori, Michael Ke Wang, Sergey Efremov, Giovanni Landoni, Ydo V. Kleinlugtenbelt, Wojciech Szczeklik, Denis Schmartz, Amit X. Garg, Timothy G. Short, Maria Wittmann, Christian S. Meyhoff, Mohammed Amir, David Torres, Ameen Patel, Kurt Ruetzler, Joel L. Parlow, Vikas Tandon, Edith Fleischmann, Carisi A. Polanczyk, Andre Lamy, Raja Jayaram, Sergey V. Astrakov, William Ka Kei Wu, Chao Chia Cheong, Sabry Ayad, Mikhail Kirov, Miriam de Nadal, Valery V. Likhvantsev, Pilar Paniagua, Hector J. Aguado, Kamal Maheshwari, Richard P. Whitlock, Michael H. McGillion, Jessica Vincent, Ingrid Copland, Kumar Balasubramanian, Bruce M. Biccard, Sadeesh Srinathan, Samandar Ismoilov, Shirley Pettit, David Stillo, Andrea Kurz, Emilie P. Belley-Côté, Jessica Spence, William F. McIntyre, Shrikant I. Bangdiwala, Gordon Guyatt, Salim Yusuf, P.J. Devereaux, Maura Marcucci, Thomas W. Painter, David Conen, Vladimir Lomivorotov, Daniel I. Sessler, Matthew T.V. Chan, Flavia K. Borges, Kate Leslie, Emmanuelle Duceppe, María José Martínez-Zapata, Chew Yin Wang, Denis Xavier, Sandra N. Ofori, Michael Ke Wang, Sergey Efremov, Giovanni Landoni, Ydo V. Kleinlugtenbelt, Wojciech Szczeklik, Denis Schmartz, Timothy G. Short, Maria Wittmann, Christian S. Meyhoff, Mohammed Amir, David Torres, Ameen Patel, Kurt Ruetzler, Joel L. Parlow, Vikas Tandon, Carisi A. Polanczyk, Raja Jayaram, Sergey V. Astrakov, Sabry Ayad, Mikhail Kirov, Miriam de Nadal, Pilar Paniagua, Hector J. Aguado, Kamal Maheshwari, Michael H. McGillion, Jessica Vincent, Ingrid Copland, Kumar Balasubramanian, Sadeesh Srinathan, David Stillo, Andrea Kurz, Emilie P. Belley-Côté, Jessica Spence, Shrikant I. Bangdiwala, Gordon Guyatt, Salim Yusuf, P.J. Devereaux, Toby Richards, John Eikelboom, Chaoran Wu, Peter Gross, Pavel Roshanov, Ian Roberts, Dean Fergusson, Pierre Foëx, Finlay McAlister, Sara Di Diodato, Rosemary Howe, Hannah MacDonald, Louise Mastrangelo, Clare McGall, Natalie Mercuri, Sarah Molnar, Trisha Southall, Jennifer Swanson, Makayla Tosh, Eric Deng, Tamara Marsden, Mark Molec, Olga Shestakovska, Robin Zhao, Mikhail Ya Yadgarov, Dmitry B. Borisov, John Gorman, Teresa Cafaro, Stefano Italiano, Andrés Valenzuela Suárez, Steffen Blum, Nuria Ruiz-López, Christian E. Haarmark Nielsen, Anna Włudarczyk, Federico Germini, Javiera Paz Vasquez, L.J. Bleijerveen, Stefan Schandelmaier, Jesse Popov, Daniel Moller, Carlos Moliner Abós, Denis Losik, Arnav Agarwal, Chantal Mulkens, Elizaveta Fisher, Pawel Wrona, Martin Sramek, Steffan F. Stella, Antonia Nucera, Franziska Kuestermann, Emmanuel Egom, Shaan Gupta, Luis Morillo, Alexander Thiel, Gillian Ormond, Louise de Prinse, Sam Lumb, Simon Macklin, Christine S. Osborn, Johanna Somfleth, Carolyn M. Wood, David Highton, Palvannan Sivalingam, Allison Kearney, Sabrina Oishi, Victoria Forrester, Edward Pilling, Sibi Mathew-Kurian, Joanne Cummins, Juanita Muller, Surbhi Malhotra, Lucy Glazov, Duncan Wright, Michael Bennett, Priscilla Marneros, Steve Cai, Natalie Pfund, Michael J. Challis, David R. Alcock, Robyn A. Seale, David Edmund Piers Bramley, Joshua Szental, Justin Yeung, Miriam Towns, Kerry Gill, Samantha Bates, Sarah R. Bowman, Amos Moody, Paul Slocomb, Peter Smedley, James Marckwald, Ross K. Kerridge, Paul Healey, Jeanene L. Douglas, Bernard D. Frost, Libia E. Machado Muñoz, Sue Chew, Andrea Barton, Amy Skiller, Sarah Boschen, Richard Bulach, Tina Maggio, Lauren Bulfin, Philip J. Peyton, Justin Nazareth, Sarah Baulch, Saskia Harris, Gayle Claxton, Bernhard Riedel, Kimberley Coleman, Jason P. Koerber, Adam D. Badenoch, Susan M. Rattigan, Vanessa J. Scotland, Helen Vlachtsis, Tomas B. Corcoran, Andrew J. Toner, Nigel J.W. Dunk, Ned W.R. Douglas, Amit Surah, Vi Ha, Alfred Tanaka Mahumani, Jennifer Cope, Elenore Clark-MacKay, Edith Fleischmann, Barbara Kabon, Christian Reiterer, Alexander Taschner, Nikolas Adamowitsch, Oliver Zotti, Seyed Javad Bidgoli, Christiane Dzechi, Céline Van Lerberghe, Hélène Tatiana Besse, Ida Stany, Mona Momeni, Audrey Dieu, Benoit Loic, Ricardo R. Bergo, Frederico C. Dall’Orto, Gislayne R. Ribeiro, Keyla C. Bitencourt, Luciana Cadore Stefani, Rosângela da Rosa Minuzzi, Andre Prato Schmidt, Debora Roberta Dornelles, Mariana Brandão, Kelly Lawrence, Philip Joseph, Patrick Magloire, Amna Ahmed, Conor Cox, Krysten Gregus, Baha Alazzoni, Jacquie Hare, Dale Williams, Dan Tushinski, Samir Raza, Shariq Haider, Amitabha Chakroborty, Shervin Zandi, Ahraaz Wyne, Jessica Huynh, Amanda Huynh, Tomas VanHelder, Susan O’Leary, John Harlock, Mohamed Panju, Kajenny Srivaratharajan, Betty Chui, Ryan Proc, Lisa Trombetta, Ted Rapanos, Shirley Pettit, Harsha Shanthanna, John Neary, Katie Connolly, Muammar Abdulrahman, Spencer Wikkerink, Faraaz Quraishi, Rahima Nenshi, Deborah A. Dumerton, Jason Erb, Jessica Shelley, Elorm Vowotor, Maria Karizhenskaia, Emile Peponoulas, Nikola Joly, Francois-Martin Carrier, Roberta Daila Carling, Eva Amzallag, Catherine Lapointe, Diane Baptiste, Mélodie Fanay Boko, Luc Massicotte, Maxime Thibault, Brigitte Migneault, Francois Plante, Francois Girard, Juan Guzman, Michael Jacka, Michelle Graham, James Greene, Derek Dillane, David Bigam, Ella McMurtry, Michael Zaugg, Jason Foerster, David Williams, Kelly B. Zarnke, Linet Kiplagat, Shannon M. Ruzycki, Evan Minty, Prism S. Schneider, Biniam Kidane, Duane Funk, Lawrence Tan, Richard Liu, Gordon Buduhan, Stephanie Enns, Emma Poole, Stuart A. McCluskey, Nour Ayach, Jo Carroll, Marcin Wasowicz, Matteo Parotto, George Djaiani, Humara Poonawala, Marko Mrkobrada, George K. Dresser, Jaclyn A. Ernst, George Nicolaou, Luc Dubois, Audra Duncan, Karen L. Broadhurst, Brogan M. Johnston, Stephanie N. Handsor, Michael R. Prystajecky, Peter D. Hedlin, Amrita Sharma, Shrijal Bhavsar, Jennifer McMullen, Marco Lefebvre, Peter Ramon Moliner, Luc Lanthier, Maite Fuentes, Valentina Paz, Alejandra Cares, Alejandra Díaz, Natalia Herrera, Tiare de la Puente, Waldo Merino, Ruben Carrasco-Moyano, Claudio Carcamo, Gavin M. Joynt, Tony Gin, Lin Zhang, Gordon Y.S. Choi, Wai Tat Wong, Linda M.L. Lai, Chi-Fai Ng, Philip W.Y. Chiu, James Y.W. Lau, Malcolm Underwood, Beaker Fung, Eva Lee, Ka Yan Hui, Chee Sam Chan, Winnie Wing Sam Chan, Sihua Qi, Yuying Xie, Mengdi Zhang, Xiaofen Liu, Ye Zhang, Rui Li Liu, Marlene Søgaard, Ossian Gundel, Viktor Moseholm, Diana B. Jensen, Mia K. Hansen, Grethe Bendixen, Anne Sofie Jensen, Sanne Dahl Thorsager Olesen, Naomi Nadler, Mette Krogh Østerby, Mojgan Vazin Kjeldsen, Jawad Ahmad Zahid, Nessn Azawi, Ismail Gögenur, Eske Kvanner Aasvang, Niels Brandt Højlund-Hansen, Theis Simon Bak, Thomas Kistorp, Martin Andreas Røder, Pascal Alfonsi, Julia Lavergne, Sarah Makoudi, Helene Beaussier, Richard K. Ellerkmann, Nicholas Kiefer, Holger Pohl, Anne Houben, Mihiri U. Amarasekara, Anke Hoffmann, Oliver Höhn, Giovanna A.L. Lurati Buse, Sebastian Roth, Alexandra Stroda, Ragnar Huhn-Wientgen, Johnnes Nienhaus, Rene M´Pembele, Antony Adelowo, Mark Coburn, Claudia Neumann, Markus Velten, Alma Puscarevic, Gregor Massoth, Rolf Rossaint, Ana Kowark, Sebastian Ziemann, Linda Grüßer, Julia Wallqvist, Pascal Kowark, Christian Bach, Mangala Rao, Freeda Xavier, Susan Maria Subbin, Keyur Bhatt, Dhaval Mangukiya, Jignesh Patel, Daxa Kachhadiya, Sanjay Thumar, Viral Parekh, B. Vishwanath, D.N.B. Sachin, Veena Gopal, D.M. Shivaraj, S. Ajay, T.S. Veena, Ravinder Singh Sidhu, Gursaran Kaur Sidhu, Naveen Laiker, Abhitej Sidhu, K. Varghese Zachariah, Anil Kumar, Venkatanarasimhan N.S., Chakravarthy Jacob Joel, Priya Pushpavathi, Vishnuvardhana G.V., Nithya Manayath, Ravi Patil, Niranjan Mallanaik, Suresh B. Patankar, Suparn K. Khaladkar, Gururaj A. Padsalgi, Prashant Vitthalrao Rahate, Shantanu P. Sengupta, Rajasi Sengupta, Suchitra S. Uikey, Kunda Mungulmare, Shashikant Sahare, Prem Haridas Menon, Rajeev Damodaran Nair Sarojini Amma, Alen Sigamani, Manesh Stephen, Mohammed Ashraf, Navneet Kumar Chaudhry, Valsamma Abraham, Rajneesh Calton, Vipul Gurjar, Honeypal Maharau, Rahul Guhabiswas, Sanjay Dhiraaj, Surendra Kumar Agarwal, Puneet Goyal, Rajneesh Kumar Singh, Sabaretnam Mayilvagnan, Anil Agarwal, Anand Prakash, Stefano Turi, Nora Di Tomasso, Giuseppe Dalessandro, Cristina Nakhnoukh, Carola Galbiati, Francesco G. Nisi, Gabriele Valsecchi, Rosalba Lembo, Francesco De Donato, Gaetano Lombardi, Barbara Ferrara, Giorgio Oriani, Tancredi Guerrerio, Cesare Donarini, Marisa Iacurti, Georges Ghanem, Claudia Brusasco, Giulia Orefice, Francesco Corradi, Michela Gandini, Michela Rosa, Silvia Di Maio, Barbara Spanio Capra, Leila Mameli, Victoria Bosio, Giuseppe De Blasio, Luigi Zagra, Paolo Perazzo, Chiara Colombo, Federica Marra, Tyng Yan Ng, Nur Azreen Hussain, Ri Qi Yeow, Yang Qun Choy, Xue Lin Chan, Yuen Sin Lai, Choo Kian Gan, Ka Ting Ng, Nor Ashikin Md Sari, Boon Koon Yoong, Wen Bin Lim, Natasha Mohd Noh, Su Sian Lim, Edwin Sze Sian Yit, Tsyr Xiang Teoh, Shu Ching Teo, Samuel E.H. Tsan, Yong Peng Lim, Soon Keong Khaw, Tze Ling Ng, Camilla J. Ngen, Abigail D.R. ak Dennis Gimang, Hran Cisca H.Y. Sim, Choo Pei Jap, Kee Chai Sia, Sze Li Siow, Seleen Cheah, Su Yin Loo, Yeh Han Poh, Yoke Yin Woo, Siti Hawa Tahir, Meng-Li Lee, Im Im Chin, Teik Hooi Khoo, Lean Wah Luah, Chow Yen Yong, Azelia Mansor, Hoong Hoong Ng, Joey J.Y. Soon, M.M. Sahul Hamid, Hema Malini Manogharan, Siti Sufia Mohd Saleh, Teh Wahida Tusirin, Sabreena Ismail, Boon Tiang Lau, Soon Keat Shio, Chun Fai Chiang, Joyce Tien, Ellie B.M. Landman, Stefan J. Gelderman, Jan-Hein M.G. Cobben, Bas Staffhorst, Roel Mes, Hannie Elskamp-Meijerman, Monique Voskamp-Wierik te, Rochel Dijkgraaf, Kim M. Welberg, Judith J. Postmus, Silke J. Wagenvoort, Felix van Lier, René van Bruchem, Frank Grüne, Elizabeth Maxwell, Douglas Campbell, Davina McAllister, Vikrant Singh, Leanda Ritchie, Sarah Dandy, Nicole Vogts, Andrew Marshall Wilson, Julius Dale-Gandar, Jane Denman, Nicholas Lightfoot, Sue Olliff, Helen Houston, Reuben Breadnam, Sioux Masters, Jonathan Termaat, Gay Mans, Kate Goldstone, Glenda Mouton, Tehreem Zahid, Sumeyya Azam, Ahmed Sohail, Yumna Hassan, Sibgha Aimon, Muhammad Uneeb, Maaz Ahmed Yusufi, Zia Nazir, Sundus Ayub Awan, Mohsin Nazir, Madeeha Rasheed, Haris Sheikh, Azhar Rehman, Amir Shariff, Zia Ur Rehman, Anila Anjum, Maciej Chwala, Anna Włudarczyk, Jacek Gorka, Dorota Studzińska, Marcin Jelinek, Gabriela Domaszewicz, Weronika Wajda, Pawel Grudzien, Anna Mirek, Bartosz Kudliński, Jarosław Zawisza, Ilona Kauf, Magdalena Wirtek, Damian Grochulski, Alexey Y. Kulikov, Mikhail A. Alexeev, Konstantin S. Trukhin, Andrey A. Cherednichenko, Irina A. Andrianova, Svetlana S. Mikhailova, Andrey A. Sorokin, Elizaveta A. Leonova, Timur A. Dzhumatov, Oleg V. Kuleshov, Alexander A. Safronov, Svetlana L. Nepomnyaschaya, Anna S. Kotova, Maxim S. Stoliarov, Dmitry V. Shmatov, Nikita S. Kubin, Nazym A. Kalieva, Dmitry D. Shkarupa, Elena A. Shirshova, Elena L. Neporada, Konstantin N. Kungurtsev, Vyacheslav V. Zhukov, Ilya G. Werner, Igor Yu. Chudnovets, Andrey A. Karpenko, Samandar M. Ismoilov, Gallina A. Zeidlits, Mikhail N. Deryagin, Pavel E. Vedernikov, Liudmila V. Lomivorotova, Alexander M. Cherniavskiy, Gleb B. Moroz, Roman V. Osinsky, Marat N. Abubakirov, Vsevolod V. Kuzkov, Ayyaz Hussain, Alexey A. Smetkin, Darja V. Carionova, Yana Y. Ilyina, Dmitrii A. Volkov, Evgenia V. Fot, Maria M. Sokolova, Maria V. Veshnyakova, Evgenia B. Lochekhina, Alexey M. Ovezov, Levan B. Berikashvili, Oleg N. Gerasimenko, Nadezhda V. Ermokhina, Ekaterina V. Ryabova, Valery V. Likhvantsev, Valerii V. Subbotin, Artem N. Kusovlev, Kristina K. Kadantseva, Andrei A. Klimov, Levan B. Berikashvili, Svetlana Tsiryatyeva, Bruce M. Biccard, Kobus Bergh, Esther Cloete, Ettienne Coetzee, Margot Flint, Marcin Nejthardt, Jan H.R. Becker, Sophie Mathijs, Bernd G. Lenhard, Leanne K. Frankish, Adrià Font, Ruben Diaz, Mar Felipe, Nerea Guadalupe, Gonzalo Azparren, Virginia Cegarra, Inma India, Aranzazu Gonzalez, Anabel Delgado, Jose Gonzalez, Daniela Garrido, Jesus Alvarez-Garcia, Juan Berrocal-Cuadrado, Elvira Mateos-Álvarez, Adela Pereda-Manso, Ángel Fernández-Collantes, David Velasco-Villanueva, Virginia García-Virto, Gregorio Labrador, Ana Zabalza, Abel Ganso, Luisa F. Álvarez-Cid, David C. Noriega, Esther Cano, Maddalena Pasini, Patricia Galan, Alejandro Madrid, Elena Camio, Marcos de Miguel, Ivette Chocron, Susana González, Dina Butron, Gemma Vidal, Maria T. Ferrer, Ana Belén Serrano, Maria Gómez-Rojo, Ángel Candela-Toha, Jose Isabel Muñoz, Manuel del Rey, Ana Castro, Beatriz Tena, Oscar Comino-Trinidad, Carla Solé, Marina Vendrell, Concepción Monsalve, Joan Beltran, Purificación Matute, Manuel López-Baamonde, Montserrat Tió, JI García Sánchez, Rodrigo Molina, Diana Zamudio, Viviana Varón, Marc Vives, Kevin Regi, Silvia Torres, Arystarch Miron Makowski, Iram Ahmed, Thyra Kyere-Diabour, Marcela P. Vizcaychipi, Patil Shashank, Jaime Carungcong, Surendini Thayaparan, Tatyana Kopyeva, David E. Traul, Rafi Avitsian, Jacek B. Cywinski, Allen Keebler, Stacy Ritzman, Sandra B. Machado, Mariel R. Manlapaz, Alparslan Turan, Praveen Chahar, Elyad Ekrami, Fabio A. Rodriguez-Patarroyo, Mauro Bravo, Barak Cohen, Hani Essber, Ruben Agudelo-Jimenez, Eva Rivas, Dominic Pelle, Michael J. Rosen, Emre Gorgun, Partha Saha, Azfar Niazi, Andrew Volio, Daniel D. Kim, Jorge Araujo-Duran, Eitan Scher, Manal Hassan, Gandhivarma Subramanium, Juan P. Cata, German Corrales, Ronaldo Purugganan, Peter Norman, Olakunle Idowu, Camila Teixeira, Syed Nasim, Edward Noguera, Santiago Luis, Mario Pimentel, Snehal Raut, Sameep Baral, Ricardo Plata Aguilar, Luz Divina Arazo, Andres Giraldo, Steven Minear, Tristan E. Weaver, Sergio D. Bergese, Alberto A. Uribe, Joshua D. Pasek, Jaume Borrell-Vega, Caitlin Hatten, Olufunke Dada, Johnny McKeown, Juan Fiorda-Diaz, Marco Echeverria-Villalobos, Michael Essandoh, Priya A. Kumar, Harendra Arora, Meena Bhatia, Scott Alan Miller, Bruce Cusson, Lynne Harris, Sydney E. Rose, Vincent Pinkert, Shamsuddin Akhtar, Miriam Treggiari, Michael Kampp
Journal: Annals of Internal Medicine (2023)

Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery.Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723).110 hospitals in 22 countries.7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications.In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery.The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment.The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term.Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels.In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.